Evaluation of the Electronic Clinical Dementia Rating for Dementia Screening

Key Points Question Is the digital, remotely administered Electronic Clinical Dementia Rating (eCDR) useful for dementia screening and assessment? Findings In this cross-sectional study including 206 adults, the eCDR continuous global score was associated with the in-clinic CDR global categorical score (area under the curve, 0.79). For 173 adults with item-level data, concordance between the eCDR and the CDR for item, box, and global scores was moderate to high, with κ statistics in the fair to moderate range. Meaning These findings suggest that the eCDR is valid and has potential for screening and assessing older adults for cognitive and functional decline related to Alzheimer disease.

Participants and study partners then received email reminders to complete the eCDR at 6-month intervals.The median time interval between the in-clinic eCDR and remote eCDR administration was 7 days (interquartile range= 4 -13 days; range = 0 -357 days; n=7 with time interval > 6 months).Analyses measuring agreement between eCDR global scores in-clinic versus remote indicated minimal effects of administration setting (Odds Ratio=0.99;95% confidence interval: 0.64-1.53,p=1).Analyses reported herein include only the remote eCDR administration.

S1.3. eCDR scoring algorithm.
The eCDR was scored automatically using a scoring algorithm we previously developed based on a bi-factor Item Response Theory (IRT) model with correlated domain-specific factors, yielding continuous and categorical box-specific and overall eCDR scores 3 .Briefly, based on 53 selected items and the Clinical Dementia Rating (CDR) latent structure, we compared the fit of four predefined models and selected the best fitting bi-factor IRT model with correlated domain scores.From this model we extracted two scores: (1) domain (box) scores: estimated as a weighted composite of the general factor and the corresponding domain specific factor; and (2) the overall (global) score: estimated as a weighted composite of the general factor and all the domain specific factors.The item discrimination parameters for the general factor and the domain specific factors were used to compute the weights according to the Bi-factor M4 method 4 .The continuous version of the eCDR scores (eCDR IRT scores) were derived from the bi-factor IRT model first, which represent the degree of impairment globally (IRT global score) and in each domain (domain specific IRT score).Categorical eCDR global and domain specific box scores were then generated by applying the optimal cutoffs previously developed 3 .For both continuous and categorical eCDR scores, higher values represent greater levels of impairment.The Home and Hobbies domain was not included in the scoring algorithm since the CDR item level dataset originally used to develop the scoring algorithm only had one item with data available 3 .S1.4.Uniform Data Set, Version 3. (UDS).UDS assessments [5][6][7][8][9][10][11][12][13][14]

eTable 1: Participant Characteristics for Participants With Available Item-Level Clinical Dementia Rating (CDR) Data
included: CDR, Montreal Cognitive Assessment (MoCA; total score, uncorrected for education), Craft Story 21 Learning (total learning, story units), Craft Story Delayed Recall (score) Benson Complex Figure Copy (copy score, total delayed recall score), Number Span Test (number correct trials, forward and backward), Trail Making A and B (completion time), Multilingual Naming (total score without semantic cue), Verbal Fluency (total correct), Functional Sensitivity analyses were conducted on a subset of participants who completed the CDR and eCDR within 14 days of each other (n=160).Correlation with UDS assessments.Correlation between eCDR global IRT score and UDS neuropsychological test scores ranged from r=0.05 (MINT naming test) to r=0.349 (Trail Making Test B)(eFigure).For all UDS assessments, correlations between UDS assessment and eCDR IRT global score were not significantly different than correlations between UDS assessment and CDR-SB score (eTable 5).Continuous variables were summarized mean ± SD, (min -max).Categorical variables were summarized as count and percentage.For race categories, "Other" is a distinct category that is a response option in the self-report race question.

eTable 2: Complete Text of eCDR Questions Included in the Item-Level Analysis
Scoring of item requires comparison of the responses from the participant and study partner.If the participant's response matches the study partner's response, the item is scored as correct.The percentage of instances in which the CDR scored the individual at a greater level of impairment than the eCDR eCDR more impaired: The percentage of instances in which the eCDR scored the individual at a greater level of impairment than the CDR judsp1In general, if you had to rate his/her abilities to solve problems at the present time, would you consider the: as good as they have ever been; good, but not as good as before; fair; poor; no ability at all memsp8 Does he/she completely forget important information from the distant past (e.g., birthdate, wedding date, place of employment)?jud7Subtract 3 from 20 and keep subtracting 3 from each new number all the way down.memsp2Canhe/sherecallrecentevents?memsp4Hasthere been some decline in memory during the past year?orisp7Howoftendoeshe/sheknowhow to get from one place to another outside of his/her neighborhood?(Usually;sometimes;rarely;don'tknow)mem4When were you born? ori2What day of the week is it?homsp5Ishe/sheableto perform household chores at the level of (pick one.Informant does not need to be asked directly): No meaningful function (performs simple activities, such as making a bed, only with much supervision); functions in limited activities only (with some supervision, washes dishes with acceptable cleanliness; sets table); functions independently in some activities (operates appliances, such as a vacuum cleaner; prepares simple meals); functions in usual activities but not at usual judsp3 Rate his/her ability to handle complicated financial or business transactions (e.g., balance a checkbook, pay bills): (no loss; some loss; severe loss) judsp4Can he/she handle a household emergency (e.g., plumbing leak; small fire)?(as well as before; worse than before because of trouble thinking; worse than before, another reason) jud3What is the difference between these things?...*

For Personal Care domain, there are only 3 participants with domain box score
≥0.5, which are not enough to perform the10-fold cross-validation and therefore cvAUCs are not provided. eFigure:

Heat Map of Correlations Between CDR or eCDR and UDS Neuropsychological Assessments UDS Assessment
Cells are color-coded according to the magnitude of the Spearman correlation.Deeper color represents higher correlation.Correlations were not significantly different between (1) eCDR IRT score and UDS assessment; (2) CDR-SB and UDS assessment.(SeeeTable 4).© 2023 Nosheny RL et al.JAMA Network Open.eTable 5: